Impact of different conduction disturbance management strategies after TAVI on 1-year clinical outcomes: the GLAM-TAVI registry

INTRODUCTION AND OBJECTIVES New-onset conduction disturbances (CDs) occur in up to 50% of patients undergoing transcatheter aortic valve implantation (TAVI). However, thresholds for permanent pacemaker implantation (PPI) vary widely among centers, resulting in 30-day implantation rates ranging from 0% to 36%. The aim of this study was to compare 1-year clinical outcomes between a standardized guideline-directed strategy and an individualized management strategy for post-TAVI CD management. METHODS The GLAM-TAVI was an investigator-initiated, ambispective study including patients who developed CDs after TAVI at 6 centers in Europe and the United States. Centers were prespecified as adopting either a standardized guideline-directed or an individualized strategy, based on the use of a watchful waiting approach during the index hospitalization for nonadvanced CDs. The primary endpoint was a composite of all-cause death or unplanned rehospitalization for CD-related events at 1 year. Time-to-event analyses used Cox models with cluster-robust standard errors and inverse probability of treatment weighting. RESULTS Among 1573 patients undergoing TAVI during the study period, 345 (21.9%) developed postprocedural CDs and constituted the study population. These patients were managed with either an individualized (n = 160) or standardized strategy (n = 185). At 1 year, the incidence of the primary endpoint was similar with the individualized and standardized strategies (13.6% vs 7.1%; aHR, 1.23; 95%CI, 0.56-2.69). Individualized management was associated with higher cardiovascular mortality (8.4% vs 1.2%; aHR, 9.10; 95%CI, 1.59-52.18) and a lower PPI rate (49.4% vs 80.2%; aHR, 0.61; 95%CI, 0.43-0.86). CONCLUSIONS In GLAM-TAVI, an individualized CD management strategy was associated with a lower PPI rate and higher cardiovascular mortality, although these findings should be interpreted with caution. These results highlight the need for structured, guideline-aligned risk stratification and rhythm surveillance when pacemaker-sparing approaches are adopted.